Medicaid Contract Purchasing SpecificationsPart 1BDelivery of Covered Items and ServicesIf, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on delivery of covered items and services is for your consideration. Table of Contents §101B. In General Commentary: The provisions in this Part address ways in which providers may deliver items and services to enrolled children. This Part was designed to enable Purchasers to specify, at their option, criteria and guidelines for the delivery of health care services to specific populations of children, or with respect to specific illnesses or conditions. For example, §101B(b) specifies the use of Bright Futures: Encounter Forms for Health Professionals (1998) for an initial assessment of an enrolled child by a provider. If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on the delivery of covered items and services is for your consideration. K§101B. In General (a) EPSDT Screening Services — Contractor shall ensure that EPSDT screening services described in §§102(b)(1) - (4) are furnished to each enrolled child on an individual basis. (b) Initial Assessment — Contractor shall ensure that providers participating in Contractor's provider network conduct initial assessments required under §601(b) of Part 6 using encounter forms set forth in Bright Futures: Encounter Forms for Health Professionals1 appropriate to the age of the child. (c) Adolescent Preventive Services — Contractor shall ensure that providers participating in Contractor's provider network comply with the requirements of §102B relating to the delivery of preventive services to enrolled adolescents. (d) Dental Services— Contractor shall ensure that providers participating in Contractor's provider network comply with the requirements of §103B relating to the delivery of dental care services to enrolled children. (e) Immunizations — Contractor shall ensure that providers participating in Contractor's provider network comply with the requirements of §104B relating to the delivery of immunizations to enrolled children. (f) STD Services — Contractor shall ensure that providers participating in Contractor's provider network comply with the requirements of §105B relating to the delivery of STD services to enrolled children. (g) HIV Services — Contractor shall ensure that providers participating in Contractor's provider network comply with the requirements of §106B relating to the delivery of HIV services to enrolled children. (h) TB Services — Contractor shall ensure that providers participating in Contractor's provider network comply with the requirements of §107B relating to the delivery of TB services to enrolled children. (i) Childhood Lead Poisoning Services — Contractor shall ensure that providers participating in Contractor's provider network comply with the requirements of §108B relating to the delivery of childhood lead poisoning services to enrolled children. (j) Diabetes Services — Contractor shall ensure that providers participating in Contractor's provider network comply with the requirements of §109B relating to the delivery of diabetes services to enrolled children. If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on the delivery of preventive services to adolescents is for your consideration. §102B. Delivery of Preventive Services to Adolescents K(a) EPSDT Screening — Contractor shall ensure that, in performing a comprehensive health and developmental history (including assessment of both physical and mental health development) covered under §102(b)(1) with respect to an enrolled adolescent, each provider participating in Contractor's provider network shall: G(1) follow the Guidelines for Adolescent Preventive Services enumerated in §006(a)(1)(B) of the Overview; and K(2) (to the extent not otherwise provided in such Guidelines) determine: (A) immunization status (consistent with guidelines enumerated in §104B); (B) pregnancy status and risk of unintended pregnancy; (C) the presence or risk of infection with a sexually transmitted disease (STD) (consistent with guidelines enumerated in §105B); (D) the presence or risk of infection with the Human Immunodeficiency Virus (HIV) (consistent with guidelines enumerated in §106B); (E) use of alcohol, tobacco, or other drugs; (F) the presence or risk of physical or sexual abuse; (G) the presence or risk of depression or related conditions; (H) the risk of suicide; (I) the risk of intentional and unintentional injuries; (J) diet and the presence or risk of eating disorders; and (K) performance at school (including involvement in community service activities). K(b) Counseling — Contractor shall ensure that, in furnishing counseling services covered under Part 1 to an enrolled adolescent, each provider participating in Contractor's provider network shall: G(1) follow the Guidelines for Adolescent Preventive Services enumerated in §006(a)(1)(B) of the Overview; K(2) (to the extent not otherwise provided in such Guidelines) counsel the adolescent with respect to: (A) physical growth and development; (B) psychosocial and psychosexual development; (C ) diet and physical activity; (D) injury prevention; (E) use of tobacco, alcohol, or other drugs; (F) reducing the risk of infection with a sexually transmitted disease (STD); (G) reducing the risk of infection with the Human Immunodeficiency Virus (HIV); and (H) reducing the risk of unintended pregnancy; and K(3) in the case of an adolescent for whom English is not a primary language, ensure that arrangements are made for carrying out paragraphs (1) and (2) through a health care professional who is fluent in the adolescent's primary language and who is qualified to carry out paragraphs (1) and (2). K(c) Confidentiality — Contractor shall ensure that, in furnishing EPSDT screening services, counseling services, family planning services and supplies, and other items and services covered under Part 1 to an enrolled adolescent, each provider participating in Contractor's provider network shall comply with the requirements of §1002(b) of Part 10 relating to confidentiality protections. §103B. Delivery of Dental Services [To be supplied upon completion of delivery of service provisions in sample purchasing specifications for dental and oral health] §104B. Delivery of Immunizations2 [To be supplied upon completion of delivery of service provisions in sample purchasing specifications for immunizations] §105B. Delivery of STD Services [To be supplied upon completion of delivery of service provisions in sample purchasing specifications for sexually transmitted disease services] §106B. Delivery of HIV Services3 [To be supplied upon completion of delivery of service provisions in sample purchasing specifications for services for HIV and HIV-related conditions] §107B. Delivery of TB Services [To be supplied upon completion of delivery of service provisions in sample purchasing specifications for tuberculosis services]
§108B. Delivery of Childhood Lead Poisoning Services4 K(a) In General — Contractor shall furnish, or arrange for the furnishing of, items and services described in subsections (b) and (c) to an enrolled child in accordance with the guidelines enumerated in subsection (d). K(b) Screening — In performing the assessment of blood lead levels required under §102(b)(1)(D) (relating to EPSDT), Contractor shall conduct screening blood lead level (BLL) tests (capillary or venous sample) to determine the presence of elevated blood lead level (EBLL) (as defined in subsection (e)) in an enrolled child at each of the following ages: (1) twelve (12) months; (2) twenty-four (24) months; (3) in the case of an enrolled child between the ages of thirty-six (36) and seventy-two (72) months who has not previously received such a test, at the child's first encounter with a provider participating in Contractor's provider network; and (4) at such other times as are required under [drafter insert any additional standards set forth in State's EPSDT periodicity schedule]. K(c) Clinical Management — In the case of an enrolled child with respect to whom a screening under subsection (b) indicates an EBLL (as defined in subsection (e)), Contractor shall: (1) conduct a diagnostic blood lead level (BLL) test (venous sample) to confirm an EBLL; and (2) in the case of an enrolled child with a confirmed EBLL, furnish clinical management of the EBLL in accordance with the guidelines described in subsection (d), to the extent that the recommended diagnostic and treatment items and services are otherwise covered under §102 (relating to EPSDT)and §103 (relating to prescription drugs). G(d) Guidelines — The guidelines enumerated in this subsection are Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health Officials (Centers for Disease Control and Prevention, 1997) www.cdc.gov/nceh/programs/lead/guide/1997/guide97.htm. K(e) Elevated Blood Lead Level (EBLL) Defined — Elevated blood lead level is a concentration of lead in whole blood (capillary or venous sample) that is equal to or greater than 10 micrograms per deciliter. §109B. Delivery of Diabetes Services [To be supplied upon completion of delivery of service provisions in sample purchasing specifications for diabetes services] Endnotes
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As discussed in the introduction to these sample Medicaid pediatric purchasing specifications, CHSRP is also developing sample purchasing specifications relating to a number of public health issues that involve benefits. Among these are sample specifications for the purchase of services relating to immunizations, tuberculosis, sexually transmitted diseases (STDs), HIV infection and HIV-related conditions, childhood lead poisoning, dental and oral health, and diabetes. Upon completion of these sample public health purchasing specifications, the relevant sections of these specifications will be incorporated into this Part.